Paeds · gastroenterology-hepatology-and-nutrition
Ascites and peritoneal disease
Also known as Paediatric ascites · Spontaneous bacterial peritonitis in children · Serum-ascites albumin gradient · Chylous ascites in children · Tuberculous peritonitis in children
Fellowship guide to ascites and peritoneal disease in children: the serum-ascites albumin gradient as the key diagnostic tool separating portal hypertension from non-portal causes, the spontaneous bacterial peritonitis polymorphonuclear threshold of 250 per cubic millimetre, the stepwise ascites management with sodium restriction, diuretics, large-volume paracentesis with albumin replacement and transjugular shunting, and the paediatric peritoneal conditions of chylous ascites, tuberculous peritonitis and meconium peritonitis.
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Red flags
- Fever, abdominal pain, or altered mental status in a child with ascites demanding an immediate diagnostic paracentesis for spontaneous bacterial peritonitis
- Tense ascites causing respiratory distress or renal compromise requiring urgent large-volume paracentesis
- Falling urine output or rising creatinine in a cirrhotic child suggesting hepatorenal syndrome
- Chylous ascites in a neonate suggesting congenital lymphatic malformation
- Cloudy or milky ascitic fluid suggesting chylous ascites or bowel perforation
- Rapidly accumulating ascites with weight loss and night sweats suggesting peritoneal tuberculosis or malignancy
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Board mappings
- Recognises ascites on clinical examination using shifting dullness and fluid thrill
- Calculates the serum-ascites albumin gradient and interprets the result
- Identifies spontaneous bacterial peritonitis as a life-threatening complication of cirrhotic ascites
- Constructs a stepwise management plan for cirrhotic ascites from sodium restriction to transplantation
- Distinguishes cirrhotic ascites from nephrotic, cardiac, chylous and tuberculous ascites using the gradient and fluid analysis
- Manages spontaneous bacterial peritonitis with antibiotics, albumin and secondary prophylaxis
- Differential diagnosis of ascites in a child and the role of the serum-ascites albumin gradient
- Diagnostic criterion for spontaneous bacterial peritonitis and the indications for diagnostic paracentesis
- Complications of large-volume paracentesis and the role of albumin replacement
- Performs and interprets the abdominal examination for ascites in a long case
- Communicates a management plan for refractory ascites and transplant assessment
- Counsels a family about spontaneous bacterial peritonitis and safety-netting
- Stage 1: Recognition of abdominal distension and the clinical signs of ascites
- Stage 2: Diagnostic paracentesis, ascitic fluid analysis and the serum-ascites albumin gradient
- Level 3: Multidisciplinary management of cirrhotic ascites and its complications
- Causes of ascites in children and the serum-ascites albumin gradient classification
- Diagnostic criteria and treatment of spontaneous bacterial peritonitis
- Diuretic strategy and large-volume paracentesis with albumin replacement in cirrhotic ascites
- History-taking and examination for a child with abdominal distension
- Interpretation of ascitic fluid and blood results
- Structured explanation of the management plan including safety-netting
- NASPGHAN approach to ascites and spontaneous bacterial peritonitis in children
- Serum-ascites albumin gradient to separate portal from non-portal causes
- Recognition and management of paediatric chylous ascites and meconium peritonitis
- Recognition of the complications of cirrhotic ascites including spontaneous bacterial peritonitis
- Shared decision-making around diuretics, paracentesis and transplant referral
- Diagnostic paracentesis as a mandatory bedside procedure in the deteriorating cirrhotic child
- Canadian approach to paediatric ascites and peritoneal disease management
- Coordinated multidisciplinary care and nutritional support
- Transition from paediatric to adult hepatology services
Overview & Definition
A child who is brought in with a swollen, tense abdomen and recent breathlessness on lying flat may be revealing ascites, the pathological accumulation of fluid within the peritoneal cavity, and the cause is far from obvious until a sample of that fluid is analysed. The single most powerful question the clinician can ask is whether the ascites is driven by portal hypertension or by something else, because that question is answered by the serum-ascites albumin gradient and it redirects the entire diagnostic and management pathway. Ascites is rarely a diagnosis in its own right. It is a sign that the liver, heart, kidneys, lymphatics, or the peritoneum itself is failing to keep fluid where it belongs. [4]
Cirrhosis is the dominant cause of ascites encountered in paediatric hepatology, and in children the leading underlying disease is biliary atresia, followed by the inherited metabolic liver diseases, autoimmune hepatitis, and cystic fibrosis liver disease. In all of these the scarred liver resists portal blood flow, sinusoidal pressure rises, and the neurohormonal cascade that retains sodium and water drives fluid across the sinusoids into the peritoneal space. Ascites in this context is a marker of decompensated cirrhosis and it carries a prognosis that is transformed only by liver transplantation. [1]
Peritoneal disease broadens the picture beyond the liver. The peritoneum can be the primary site of disease in tuberculous peritonitis, in peritoneal seeding of malignancy, and in neonatal meconium peritonitis from in-utero bowel perforation. The lymphatics can fail in chylous ascites, producing milky fluid that points to a congenital lymphatic malformation in an infant or to obstruction in an older child. What unifies all of these is that the peritoneal cavity is telling a story, and the story is read by tapping it. [5]
References10ShowHide
- [1]Runyon BA Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology, 2013.PMID 23463403
- [2]de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, et al Baveno VII - Renewing consensus in portal hypertension. J Hepatol, 2022.PMID 35120736
- [3]Sort P, Navasa M, Arroyo V, et al Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med, 1999.PMID 10432325
- [4]Runyon BA, Montano AA, Akriviadis EA, et al The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med, 1992.PMID 1616215
- [5]Fernández J, Bauer TM, Navasa M, et al Diagnosis, treatment and prevention of spontaneous bacterial peritonitis. Baillieres Best Pract Res Clin Gastroenterol, 2000.PMID 11139350
- [6]Kaplan DE, Ripoll C, Thiele M, Fortune BE, et al AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology, 2024.PMID 37870298
- [7]Tufoni M, Zaccherini G, Caraceni P, et al Albumin: Indications in chronic liver disease. United European Gastroenterol J, 2020.PMID 32213034
- [8]Malvi A, Verma N, Khatib MN, et al Impact of Quinolone Prophylaxis on Spontaneous Bacterial Peritonitis and Mortality in Cirrhosis Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. JGH Open, 2025.PMID 40247847
- [9]Ginès P, Titó L, Arroyo V, et al Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology, 1988.PMID 3360270
- [10]Rudra OS, Poyekar S, Nagral A Pediatric Budd-Chiari Syndrome: A Systematic Review of Etiology, Diagnosis, and Management. J Clin Exp Hepatol, 2026.PMID 42232136